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ABSTRACT: The growing disparity between organ availability for transplantation and the number of patients in need has challenged the donation and transplantation community of practice to develop innovative processes, ideas, and techniques to bridge the gaps. Advances in the sharing of best practices in the donation community have contributed greatly over the last 8 years. Broader sharing of updated guidelines for declaration of brain death in conjunction with improvements in deceased donor management have increased opportunities for organ donation. New techniques for organ preservation and organ resuscitation have allowed for better utilization of the potential donor pool. This review will highlight processes, ideas, and techniques in organ donation.
Mount Sinai Journal of Medicine A Journal of Translational and Personalized Medicine 05/2012; 79(3):351-64. · 2.00 Impact Factor
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ABSTRACT: The disparity between organ supply and demand has necessitated more aggressive use of livers from extended criteria donors. Organ sharing between donor service areas and transplant centers in other regions is common. Confidence in the graft quality is greatly improved with a digital image taken in conjunction with the recovery surgeon's report and biopsy data. Three cases in which digital images of various levels of quality allowed the recipient's surgery to proceed, minimized the cold ischemia time, and yielded excellent outcomes are described. Another case in which a picture was not available and the liver was discarded after importation is also presented for comparison.
Progress in transplantation (Aliso Viejo, Calif.) 03/2010; 20(1):14-7. · 1.03 Impact Factor
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Kidney International 11/2009; 76(9):1012. · 6.61 Impact Factor
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Transplantation 10/2009; 88(5):748-9. · 4.00 Impact Factor
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ABSTRACT: The aim of this study was to outline the surgical management and outcomes for patients diagnosed with intravenous leiomyomatosis with intracardiac extension at a single institution.
This was a retrospective review of patients diagnosed with intravenous leiomyomatosis with intracardiac extension between 2002-2008.
Four patients were identified. The surgical approach in 3 (75%) patients was a single-stage operation. Four (100%) patients presented with cardiac symptoms: 3 (75%) with syncope and 1 (25%) with an abnormal electrocardiogram. Mean age at presentation was 48 years (range, 42-58 years). Complete resection of tumor was obtained in 1 (25%) patient and 3 (75%) patients experienced incomplete resection. Mean follow-up, including surveillance imaging, was 25.5 months (range, 8-57 months) and all 4 patients (100%) are currently free of recurrence.
Surgical excision remains an effective therapy for treating patients with benign metastasizing leiomyomatosis. Incomplete surgical resection may result in favorable response.
American journal of obstetrics and gynecology 10/2009; 201(6):574.e1-5. · 3.28 Impact Factor
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James V Guarrera, Michael J Goldstein,
Benjamin Samstein,
Scot Henry,
Christopher Reverte,
Ben Arrington,
Tod Brown,
Theresa K Coleman,
Gabriel Mattei,
Natasha Mendez,
Joan Kelly,
Lloyd E Ratner
Transplant International 09/2009; 23(4):444-6. · 2.92 Impact Factor
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ABSTRACT: Sustained virological response SVR is defined as undetectable HCV RNA in plasma 6 months after therapy has been discontinued. Relapse or re-emergence of viremia after SVR is rare. We report two patients that relapsed when immune suppressive therapy was given within a few weeks of achieving SVR. Patient 1 received prednisone for bronchitis and patient 2 relapsed soon after immune suppression was started post renal transplantation. These data suggest that the early phase of SVR might be associated with incomplete protective immunity. They suggest that sterilizing immunity with complete elimination of virus is unlikely. The cases also caution against the use of immune suppressive therapy in the immediate aftermath of SVR.
Journal of Medical Virology 11/2008; 80(10):1720-2. · 2.82 Impact Factor
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ABSTRACT: Limited middle segment pancreatectomy, or central pancreatectomy, has been described for sparing normal pancreatic tissue during resection of benign neoplasms of the pancreatic neck. Anatomic reconstruction after central pancreatectomy has been reported in other series with creation of a Roux-en-Y loop of jejunum for a mucosa-to-mucosa pancreaticojejunostomy.
Hospital charts and outpatient records were reviewed for 12 consecutive patients undergoing central pancreatectomy from August 1999 to November 2002.
We performed central pancreatectomy with pancreaticogastrostomy in 12 patients: 5 with serous cystadenomas, 6 with mucinous cystadenomas, and 1 with neuroendocrine tumor. All tumors were located in the body or neck of the pancreas, measuring a mean +/- standard deviation (SD) of 2.5 +/- 1.2 cm. Median postoperative hospital stay was 6.5 days (range 5 to 15 days). There were no intraoperative complications. Perioperative complications included two urinary tract infections and one readmission for acute pancreatitis. There were no pancreatic leaks or fistulas in this series. Two of the 12 patients experienced endocrine insufficiency with elevated glycosylated hemoglobin levels during outpatient followup. None of the 12 patients experienced exocrine insufficiency.
Central pancreatectomy with pancreaticogastrostomy reconstruction is safe and technically advantageous over Roux-en-Y pancreaticojejunostomy, and should be considered a safe reconstruction technique after central pancreatectomy for benign disease.
Journal of the American College of Surgeons 07/2004; 198(6):871-6. · 4.55 Impact Factor
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Michael J Goldstein,
Ephrem Salame,
Sandip Kapur,
Milan Kinkhabwala,
Diane LaPointe-Rudow,
Patricia Harren N P,
Steven J Lobritto,
Mark Russo,
Robert S Brown,
Guellue Cataldegirmen,
Alan Weinberg,
John F Renz,
Jean C Emond
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ABSTRACT: Over the past decade we have reported excellent outcomes in pediatric living-donor liver transplantation (LDLT) with recipient survival exceeding 90%. Principles established in these patients were extended to LDLT in adults. To compare outcomes in donors and recipients between adult and pediatric LDLT in a single center, we reviewed patient records of 45 LDLT performed between 1/98 and 2/01: 23 adult LDLT (54 +/- 6.5 yr) and 22 pediatric LDLT (33.7 +/- 53.5 months). Preoperative liver function was worse in adults (International Normalized Ratio [INR] 1.5 +/- 0.4 vs. INR 1.2 +/- 0.5; p = 0.032). 4 adults (17%) met criteria for status 1 or 2A. Only 1 child was transplanted urgently. Analysis included descriptive statistics and Kaplan-Meier estimation. Donor mortality was 0% with 1 re-exploration, 2.4%. Median hospital stay (LOS) was 6.0 days (range, 4-12 days). Donor morbidity and LOS did not differ by sex, extent of hepatectomy, or adult and pediatric LDLT ( p = 0.49). In contrast, recipient outcomes were worse for adults. Adult 1 year graft survival was 65% (3 retransplants [ReTx], 5 deaths) vs. 91% for children (1 ReTx, 1 death) p = 0.02. Graft losses in adults were due to sepsis (n = 3), small for size (n = 2), suicide, and hepatic artery thrombosis (HAT), whereas in children graft losses were due to portal thrombosis and total parenteral nutrition (TPN) liver failure. Biliary leaks occurred in 22% of adults and 9% of children. Hepatic vein obstruction occurred in 17% of adults and in none of the children. Median LOS was comparable (adult, 16.5 days (range, 7-149 days); child, 17 days (range, 10-56 days), p = 0.2). Graft function (total bilirubin (TBili) < 5mg/dl, INR < 1.2, aspartate aminotransferase (AST) < 100 U/l) normalizing by day 4 in children and by day 14 in adults. Adults fared worse, with an array of problems not seen in children, in particular, hepatic vein obstruction and small-for-size syndrome. Biliary leaks were diagnosed later in adults and were lethal in 3 cases; this was later avoided with biliary drainage in adult recipients. Finally, use of LDLT in decompensated adults led to death in 3 of 4 patients, and should be restricted to elective use.
World Journal of Surgery 03/2003; 27(3):356-64. · 2.36 Impact Factor
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ABSTRACT: The progressive shortage of liver donors has mandated investigation of living-donor transplantation (LDT). Concerns about increasing risk to the donor are evident, but the impact of the degree of parenchymal loss has not been quantified. We analyzed clinical and biological variables in 45 LDT performed by our team over 2years to assess risks faced in adult LDT. All donors are alive and well with complete follow-up through to February 2001. When the three operations were compared, right hepatectomy (RH) was significantly longer in terms of anesthesia time and blood loss compared with left hepatectomy (LH) and left lobectomy (LL). Donor remnant liver was significantly reduced after RH compared with LH and LL. There were significant functional differences as a consequence of the remnant size, measured by an increase in peak prothrombin time after RH. RH for adults represents a markedly different insult from pediatric donations in terms of parenchymal loss and early functional impairment. Left hepatectomy donation offers modest advantage over right lobes but seems to confer substantial technical risk for a small gain in graft size. Unless novel strategies are developed to enhance liver function of the LH graft in the adult recipient, right lobe donation will be necessary for adult LDT.
American Journal of Transplantation 10/2002; 2(8):780-8. · 6.39 Impact Factor
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Current Surgery 63(6):397-400.
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ABSTRACT: A review of surgical residents' duty-hours prompted a Work Hours Assessment and Monitoring Initiative (WHAMI) that preemptively limits residents from violating "duty-hours rules."
Work hours data for the Department of Surgery were reviewed over 8-months at New York Presbyterian Hospital-Columbia Campus. This ongoing review is performed by a work-hours monitoring team, which supervises residents' hours for the initial 5-days of each week. As residents approach work-hours limits for the week, they are dismissed from duty for appropriate time periods in the remaining 2 days of the week.
The work-hours data entry compliance for 52 residents was increased from 93% to 99% after creation of the WHAMI. Before the new system, a mean of 9.5 residents per month (19%) worked an average of 7.3 +/- 6.4 hours over the 80-hour limit. Averaged monthly compliance with the 80-hour work limit was increased to 98% with introduction of the WHAMI. A review of on-call duty hours revealed a mean of 7 (14%) residents per month who worked an average of 2.4 hours beyond 24-hour call limitations including "sign-out" time imposed by the ACGME. New monitoring procedures have improved compliance to 100% with 24-hour call limitations imposed by the ACGME. Compliance with the more stringent New York State (NYS) guidelines has approached 94% with noncompliant residents extending on-call hours by an average of 1.5 hours over the 24-hour limitations, most on "off General Surgery" rotations or out-of-state rotations. Review of mandatory rest periods contributed to an increase in mean "time off" between work periods, thereby increasing compliance with ACGME guidelines and NYS regulations from 75% to 88%, and 90% to 98%, respectively. Residents reporting less than 10 hours rest reported increased "time off" from 6.2 +/- 2.0 to 7.9 +/- 1.3 hours (p < 0.001).
Internal review of surgical resident's duty-hours at a large university hospital revealed that despite strict scheduling and the requirement of mandatory duty-hours entry, achieving the goals of meeting the duty-hours requirements and of ongoing data entry required the creation of a resident enforced, real-time Work Hours Assessment and Monitoring Initiative.
Current Surgery 62(1):132-7.
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ABSTRACT: New York State Code 405 and societal/political pressure have led the RRC and ACGME to mandate strict limitations on resident work hours. In an attempt to meet these limitations, we have switched from the previous Q3 call schedule to a specialized night float (NF) system, the continuity-care system (CCS). The purpose of this CCS is to maximize resident duty time spent on direct patient care, operative experience, and outpatient clinics, while reducing duty hours spent on performing routine tasks and call coverage. The implementation of the CCS is the fundamental step in the restructuring of our residency program. In addition to a change in the call system, we added physician assistants to aid in performing some service tasks. We performed a 360 degrees evaluation of this work in progress.
In May 2002, the standard Q3 call system was abolished on the general surgery services at the New York Presbyterian Hospital, Columbia campus. Two dedicated teams were created to provide day and night coverage, a day continuity-care team (DCT) and a night continuity-care team (NCT). The DCTs, consisting of PGY1-5 residents, provide daily in-house coverage from 6 AM to 5 PM with no regular weekday night-call responsibilities. The DCT residents provide Friday night, Saturday, and daytime Sunday call coverage 3 to 4 days per month. The NCT, consisting of 5 PGY1-5 residents, provides nightly continuous care, 5 PM to 6 AM, Sunday through Thursday, with no other weekend call responsibilities. This system creates a schedule with less than 80 duty hours per week, on average, with one 24-hour period off a week, one complete weekend off per month, and no more than 24 hours of consecutive duty time. After 1 year of use, the system was evaluated by a 360 degrees method in which residents, residents' spouses, nurses, and faculty were surveyed using a Likert-type scale. Statistical significance was calculated using the Student t-test. Patient satisfaction was measured both by internal review of a patient complaint database as well as by the Press Ganey patient satisfaction surveys.
Twenty-one residents, 10 residents' spouses, 11 general surgery faculty, and 16 nurses were surveyed. Statistically significant findings included reduced resident fatigue noted by all groups (residents, p = 0.01; resident spouses, p = 0.05; faculty, p < 0.0001; nurses, p < 0.0001). Further, residents reported more time for sleep at home (p = 0.0005) and more time for independent reading (p = 0.01). Residents' spouses reported increased availability for family events (p = 0.01). Nurses reported increased availability of residents (p = 0.0002), shorter times to physician identification of patient problems (p = 0.0086), improved resident-nursing communications (p = 0.0096), and increased ease of nursing duties (p < 0.0001). Faculty were the only responders who felt that continuity of patient care suffered with the new system (p = 0.02). The Press Ganey review showed improvement in the quality of care rendered as perceived by patients.
The institution of a specialized NF or CCS for in-house coverage of general surgical services in a large metropolitan university hospital has had initial success in meeting the mandated changes in resident work hours. The CCS reduced resident fatigue, improved quality of resident life, and improved patient care as judged by patients and nurse.
Current Surgery 61(5):445-51.
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ABSTRACT: Liver transplantation is an acceptable treatment modality for complications of end-stage liver disease from chronic and acute liver failure. In the United States, 16 377 people are currently awaiting liver transplant but only 6492 transplantations were performed in 2007. All options for liver transplantation including Model for End stage Liver Disease allocated, expanded criteria deceased donors, and live donor liver transplantation should be discussed with potential recipients on the waitlist to create an early access plan for safe and expeditious transplantation. After transplantation, careful management to avoid complications and intervene early is necessary. Common postoperative complications include graft dysfunction, vascular thrombosis, biliary tract complications, infection, rejection, neurologic injury, electrolyte imbalances, and drug interactions. A multidisciplinary approach to care including the critical care nurse is necessary for successful long-term outcomes.
Critical care nursing quarterly 31(3):232-43.
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Michael J Goldstein
Current Surgery 60(3):321-3.
